1 CARING FOR TRAFFICKED PERSONS GUIDANCE FOR HEALTH PROVIDERS
2 The opinions expressed in the report are those of the authors and do not necessarily reflect the views of the International Organization for Migration (IOM). The designations employed and the presentation of material throughout the report do not imply the expression of any opinion whatsoever on the part of IOM concerning the legal status of any country, territory, city or area, or of its authorities, or concerning its frontiers or boundaries. IOM is committed to the principle that humane and orderly migration benefits migrants and society. As an intergovernmental organization, IOM acts with its partners in the international community to: assist in meeting the operational challenges of migration; advance understanding of migration issues; encourage social and economic development through migration; and uphold the human dignity and well-being of migrants. Editors: Cathy Zimmerman London School of Hygiene & Tropical Medicine Gender Violence & Health Centre Rosilyne Borland International Organization for Migration Migration Health Division Publisher: International Organization for Migration 17 route des Morillons 1211 Geneva 19 Switzerland Tel: Fax: Internet: ISBN International Organization for Migration (IOM) London School for Hygiene and Tropical Medicine (LSHTM) United Nations Global Initiative to Fight Trafficking in Persons (UN.GIFT) All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise without the prior written permission of the publisher. 07_09
3 CARING FOR TRAFFICKED PERSONS GUIDANCE FOR HEALTH PROVIDERS
5 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS i Acknowledgements This handbook was made possible through the generous support of the United Nations Global Initiative to Fight Trafficking in Persons. The development of this handbook was coordinated by the International Organization for Migration and the Gender Violence & Health Centre of the London School for Hygiene & Tropical Medicine. We were privileged to facilitate a broad group of health and human trafficking experts from around the world in the development of Caring for Trafficked Persons: Guidelines for Health Providers. Principal authors and contributors included Dr. Melanie Abas (Institute of Psychiatry, Kings College London), Dr. Idit Albert (Centre for Anxiety, Disorders and Trauma, South London & Maudsley NHS Foundation Trust), Dr. Islene Araujo (Migration Health Department, International Organization for Migration), Hedia Belhadj-El Ghouayel (United Nations Population Fund), Rosilyne Borland (Migration Health Department, International Organization for Migration), Jenny Butler (United Nations Population Fund), Sarah Craggs (Counter- Trafficking Division, International Organization for Migration), Dr. Michele Decker (Harvard School of Public Health), Dr. Sean Devine (Independent Consultant), Riet Groenen (United Nations Population Fund), Takashi Izutsu (United Nations Population Fund), Dr. Elizabeth Miller (UC Davis School of Medicine), Dr. Nenette Motus (Regional Office for Southeast Asia, International Organization for Migration), Tina Nebe (United Nations Population Fund), Dr. Anula Nikapota (Institute of Psychiatry, UK-Sri Lanka Trauma Group), Marija Nikolovska (Regional Office for Southern Africa, International Organization for Migration), Siân Oram (doctoral candidate, LSHTM), Donka Petrova (Animus Foundation), Dr. Clydette Powell (Bureau for Global Health, US Agency for International Development), Kate Ramsey (United Nations Population Fund), Timothy Ross (Fundación Social Fénix), Dr. Jesus Sarol (Migration Health Department, International Organization for Migration), Maria Tchomarova (Animus Foundation), Leyla Sharafi (United Nations Population Fund), Dr. Amara Soonthorndhada (Institute
6 ii CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS for Population and Social Research, Mahidol University), Aminata Toure (United Nations Population Fund), Jacqueline Weekers (Migration Health Department, International Organization for Migration), Dr. Katherine Welch (Global Health Promise), Dr. Brian Willis (Global Health Promise), Dr. David Wells (Victorian Institute of Forensic Medicine), Dr. Teresa Zakaria (IOM Jakarta, International Organization for Migration), and Dr. Cathy Zimmerman (London School for Hygiene & Tropical Medicine). Many peer reviewers from around the world supported our authors. Special thanks to Dr. Jane Cottingham, Dr. Claudia Garcia Moreno, Dr. Jason Sigurdson and Dr. Susan Timberlake for ensuring we had detailed inputs from a range of colleagues at the World Health Organization and the United Nations Joint Programme on HIV/AIDS. The handbook would not have been possible without the ongoing support and guidance of Dr. Davide Mosca, Director of the Migration Health Department of the International Organization for Migration and Richard Danziger, Director of the International Organization for Migration s Counter-Trafficking Division.
7 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS iii Table of Contents Acknowledgements... i Introduction... 1 Chapter 1: Human trafficking... 7 Chapter 2: The health consequences of human trafficking Chapter 3: Guiding principles Action Sheet 1: Trauma-informed care Action Sheet 2: Culturally appropriate, individualized care Action Sheet 3: Working with interpreters Action Sheet 4: Comprehensive health assessment Action Sheet 5: Special considerations when examining children and adolescents Action Sheet 6: What to do if you suspect trafficking Action Sheet 7: Protection and security Action Sheet 8: Self-care Action Sheet 9: Patient data and files Action Sheet 10: Safe referrals Action Sheet 11: Urgent care Action Sheet 12: Mental health care Action Sheet 13: Sexual and reproductive health Action Sheet 14: Disability Action Sheet 15: Infectious diseases Action Sheet 16: Medico-legal considerations Action Sheet 17: Interactions with law enforcement Conclusion Bibliography
9 INTRO DUC TION Introduction
11 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 1 Introduction Human trafficking is a harmful and sometimes deadly practice whereby individuals are enticed by jobs and hopes for a better future into a cycle of migration and exploitation. Trafficking of persons has been called: a criminal act a human rights violation a form of exploitation an act of violence. For health care providers, trafficking in persons is best understood as a very serious health risk, because trafficking, like other forms of violence, is associated with physical and psychological harm. Evidence on human trafficking and exploitation indicates that no region of the world is free of the practice: Trafficking patterns exist in South, Central and North America, Africa, Europe, Asia and in the Pacific. The widespread nature of trafficking suggests that a health provider may at some point come into contact with a person who has been trafficked. A trafficked person may be referred to a health care provider; a patient may disclose a trafficking experience; or a provider may detect signs that suggest an individual has been trafficked. The informed and attentive health care provider can play an important role in assisting and treating individuals who may have suffered unspeakable and repeated abuse. In fact, health care is a central form of prevention and support in the network of anti-trafficking assistance measures. Purpose of the guidance This document aims to provide practical, non-clinical guidance to help concerned health providers understand the phenomenon of human
12 2 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS trafficking, recognize some of the health problems associated with trafficking and consider safe and appropriate approaches to providing health care for trafficked persons. It outlines the health provider s role in providing care and describes some of the limitations of his or her responsibility to assist. This resource attempts to respond to questions such as: What special approaches are required for diagnosis and treatment of a patient who has been trafficked? and What can I do if I know or suspect someone has been trafficked? Victims of trafficking, like victims of other forms of abuse, sustain injuries and illnesses that frequently fall to the health sector to address in a safe and confidential way. For a trafficked person, contact with someone in the health sector may be the first or only opportunity to explain what has happened or ask for help. Special note: Human trafficking is a crime that can be easily confused with other high-risk situations of migrants, including people smuggling and labour exploitation. Although there are legal distinctions between trafficking, smuggling and abusive labour conditions, there are often commonalities between the health risks and needs of people in these different circumstances. For health providers, distinctions in category should not affect the level of care they provide but may be important in determining which referral options they can use. All persons deserve and are entitled to health support and assistance based on human rights and humanitarian principles. Although this document focuses on trafficked persons, its guidance is designed to be inclusive, with information that may be useful for meeting the health needs of other marginalized or abused populations. The aim is achieving the best health for all. Target audience These recommendations are written for health providers who may now or in the future provide direct health care services for individuals who have been trafficked. They are designed to accommodate varying degrees of contact with and involvement in the care and referral of people who have been trafficked. The intended audience includes the following: general practitioners and primary care providers private and public health providers emergency room staff
13 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 3 health centre staff, such as receptionists or technical staff clinicians, e.g., gynaecologists, neurologists, infectious disease specialists outreach care providers in fields such as sexual health or refugee/migrant health mental health care professionals, e.g., psychologists or psychiatrists. These guidelines should be made accessible to all providers involved with direct care of trafficked persons. The care approaches described should, to the extent possible, be supported by training and sensitization to ensure appropriate and consistent implementation. Additionally, while this document offers guidance on good practice, different settings will undoubtedly have varying health care contexts and available resources. Recommendations should be adapted to local contexts. Chapters and action sheets: what they are and how to use them To encourage the use of these documents by busy health providers, this resource offers the main points of required knowledge and recommended approaches in a succinct manner. This document can be read in sequence or by topic of interest, therefore some concepts are repeated in different action sheets, where relevant. However, if you or your colleagues are unfamiliar with the phenomenon of trafficking or its health risks and consequences for trafficked persons, it is recommended that you read the introductory chapters first. The guidelines begin with three chapters that provide: background information on human trafficking current knowledge on the health risks and consequences of trafficking guiding principles in the care of trafficked persons. These chapters are followed by 17 action sheets covering the following general areas: tools for the patient encounter, such as trauma-informed care and culturally and linguistically responsive care; approaches to various aspects of medical care, such as comprehensive health assessment, acute care, communicable diseases, and sexual and reproductive health; strategies for referral, security and case file management, and coordination with law enforcement.
14 4 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS Each action sheet begins with a rationale offering a basic description of the subject and its significance. This is followed by an outline of required actions providing guidance on the particular area of care or strategy. At the end of most chapters and action sheets is a section on references and further resources to complement and support the information provided. Overall, this guidance document draws from many sources, including such items as other guidelines, tools and standards; research and background materials; and other resources developed by the World Health Organization, the United Nations, non-governmental organizations and academic sources. It is heavily informed by years of collective experience in addressing the consequences of human trafficking of the expert group that compiled the document. The principles and recommendations in this document are grounded in international norms and United Nations conventions. A complete list of all references is provided at the end of the book. Current evidence on trafficking encompasses primarily the most extreme cases of trafficking, which generally involve severe abuse. The recommendations in this document tend to offer suggestions for treating those who are most affected by a trafficking experience. However, in reality, not all trafficking cases involve extreme abuse and not all trafficked persons experience profound post-trauma reactions. As more trafficking cases come to light in the coming years and individuals feel safer to disclose trafficking experiences, increasingly, cases that are less severe will be reported. Providers should readily adapt the advice in this document to meet the varying level of needs of their patients. Making a difference The abuses involved in human trafficking can pose many health risks. In many cases, individuals experience physical and psychological damage and fears that seem overwhelming. The health provider who encounters a trafficked person or other exploited individual has a unique opportunity to provide essential medical care and vital referral options that may be an individual s first step towards safety and recovery.
15 CHAP TER ONE Chapter 1: Human Trafficking
17 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 7 Chapter 1: Human trafficking For health providers to provide safe and appropriate care to persons who have been trafficked, it is useful to understand the nature of human trafficking and the context of individuals who have been trafficked. This chapter offers basic information about human trafficking and gives a sense of the characteristics and dynamics of what is, in reality, a very complex and diverse phenomenon. What is the definition of trafficking? The most widely accepted definition of trafficking in persons is found in the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime: (a) Trafficking in persons shall mean the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation. Exploitation shall include, at a minimum, the exploitation of the prostitution of others or other forms of sexual exploitation, forced labour or services, slavery or practices similar to slavery, servitude or the removal of organs; (b) The consent of a victim of trafficking in persons to the intended exploitation set forth in subparagraph (a) of this article shall be irrelevant where any of the means set forth in subparagraph (a) have been used; (c) The recruitment, transportation, transfer, harbouring or receipt of a child for the purpose of exploitation shall be considered trafficking in persons even if this does not involve any of the means set forth in subparagraph (a) of this article; (d) Child shall mean any person under eighteen years of age. 1 1 Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, United Nations, New York, 2000, Article 3. See
18 8 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS Key features of the crime include movement or confinement of an individual, accompanied by coercion and exploitation, usually for the financial profit of the trafficker. How many people are trafficked? Although human trafficking is recognized as a global phenomenon, there are no reliable statistics on how many people are trafficked. It is clear, however, that this is a global crime that is not abating, because it is both profitable and difficult to detect. What types of trafficking-related exploitation are common? Individuals may be trafficked and exploited in a variety of ways. The trafficking of women and children for sexual exploitation has been the most commonly recognized form of trafficking. Yet, many, if not more, men, women and children are trafficked for such forms of labour exploitation as work in factories, in the agriculture, construction, fisheries, textile, and mining industries, and for domestic servitude and care services. Traffickers frequently target children for begging, domestic servitude, adoption and petty street theft. Who are traffickers? There is no single profile of those who traffic and exploit others. A trafficker may be female or male, a member of an organized crime network, part of a small family business or an amateur operator who assists, for example, in the transportation, documentation or logistics of a trafficking operation. Family members, friends and acquaintances of the person who has been trafficked may have participated in or lead the recruitment or other stages of the trafficking and exploitation process. Some traffickers are former victims of trafficking who now recruit and control other victims. Who do traffickers recruit? Poverty, unemployment, war, natural disasters and desperation are good predictors of vulnerability to being trafficked. However, those who fall prey to traffickers may also be relatively wealthy, relatively educated and come from urban centres. Where are people trafficked to and from? While international trafficking is often in the spotlight, people who are trafficked may be transported internationally, regionally or, as is the case with many trafficked persons, within their own national borders. Each region has common routes, many of which lead trafficked persons from areas of relative poverty to locations of relative wealth. What types of abuse do trafficked persons suffer? Trafficking is a crime that is not always evident, its victims not always readily identifiable. It is a form of violence that occurs on a spectrum. Some individuals will suffer extreme physical abuse or torture-like violence, such as beating, burning,
19 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 9 rape and confinement, while others may be subjected to less obvious but nonetheless coercive and menacing tactics, including physical and verbal threats to themselves or their families (particularly those with children). Coercive measures may include blackmail, extortion, lies about an individual s ability to gain help from police or others, warnings about being imprisoned for immigration or other crimes and confiscation of such vital identity documents as passports and personal identity cards. Why do trafficked persons stay in exploitative situations? People who are trafficked very often perceive no other option than to remain under the control of traffickers. Traffickers use common control tactics to force, manipulate and manage victims. Tactics may include: physical, sexual and psychological violence; debt-bondage; threats against family members; lies and deceit; withholding documents, maintaining victims in unpredictable or uncontrollable conditions; and emotional manipulation. When individuals are transported to unfamiliar locations, particularly to places where they do not speak the local language, it is extremely difficult for them to know where to go for help, whom to trust (many come from places where law enforcement is corrupt or indifferent) or how to ask for assistance, and how to navigate an unfamiliar city or remote area. Individuals may fear reprisals for escape attempts or feel afraid of being arrested and imprisoned. Those trafficked outside their home country may fear deportation and returning indebted and without the income that may have been promised them. Paradoxically, many individuals often, therefore, place their hopes for returning home safely in the hands of the very individuals who are exploiting them. What is the trafficking cycle? Human trafficking is best understood as a process rather than a single act (see figure 1). 2 The trafficking cycle begins at the pre-departure or recruitment stage, followed by the travel and destination/exploitation stages. Upon release or escape from the period of exploitation, individuals are often received and/or detained by authorities after which they enter the integration (if remaining at destination) or re-integration (if returned home) stage. Each stage of this cycle poses risks to an individual s health, as well as opportunities for health care professionals and others to intervene with information and assistance. 2 This section is based on the conceptual models and study findings developed in Zimmerman, C. et al., The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European study, London School of Hygiene and Tropical Medicine, London, 2003.
20 10 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS Figure 1: Stages of the trafficking cycle 3 Pre-departure/ recruitment Travel Destination/ exploitation Reception/ detention Integration/ reintegration The complex circumstances of trafficked persons The situation of individuals who are trafficked is almost always complicated. Whether still under a trafficker s control, trying to leave or already out of the trafficking environment, trafficked persons are generally mired in difficult physical, psychological, social, legal and, not least, financial circumstances. To care for individuals who have been trafficked, it is helpful to try to imagine how the world might look through their eyes. Individuals who are still in a trafficking situation may: 4 not know or understand what trafficking is. have limited personal freedom and feel trapped with no way out. work under pressure to pay off debts or feel the burden of a family financial crisis. fear reprisals from traffickers or employers. work in an informal sector or illicit industry, or in unhealthy, hazardous or dangerous conditions. worry about their legal status. be moved regularly from place to place, venue to venue. be susceptible to penalties, fines or punishment by traffickers or employers. lie about legal status, age, country of origin, family or relationship with trafficker. worry about the safety and well-being of family at home, especially when traffickers know the location of their family. 3 Based on the conceptual models and study findings developed in Zimmerman, C. et al., The Health Risks and Consequences of Trafficking in Women and Adolescents: Findings from a European study, London School of Hygiene and Tropical Medicine, London, Adapted from Zimmerman, C. and C. Watts, WHO Ethical and Safety Recommendations for Interviewing Trafficked Women, World Health Organization, Geneva, 2003.
21 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 11 suffer traumatic reactions that affect their ability to remember, trust others, react appropriately, estimate risk and seek or accept assistance. view the situation as only temporary and envision a future time when they will eventually earn sufficient income. be wary of officials of any type, including health providers. seek assurances that they are not to blame for what happened to them. Individuals who are out of a trafficking situation may: 5 experience many of the same concerns of individuals who are still in a trafficking situation (see above). continue to feel (or be) watched, followed and vulnerable to retribution against themselves or family members. have outstanding debts and/or few financial resources. have an unstable living situation, have temporary residency, fear imminent removal or deportation, or remain undocumented. wish to return home, but not have the means. not wish to return home because of abusive, deprived or dangerous past circumstances. keep their experience secret from friends, family and others. feel ashamed and stigmatized. feel independent and empowered by the experience and not wish to be treated like a victim. feel pressured to participate in a legal proceeding against traffickers, or feel in danger because of such participation. envision no alternative but to return to the traffickers. continue to experience extreme stress reactions that affect physical, sexual, psychological and social functioning. feel that talking about the past is reliving it. be unable to use health or other resources because of financial circumstances, legal status, language barriers, logistics concerns or alienation. Any one of these reactions can make seeking help difficult for a trafficked person. Once an individual is able to access care, these sensitivities, particularly shame, can make disclosing concerns, posing questions and expressing frustrations stressful. People who have been trafficked need assurance that they are not to blame for what happened to them. They also need to regain a sense of being respected and accepted. 5 Ibid.
22 12 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS Particular complexities Some trafficker-victim situations are particularly complex, and may pose special challenges in work with trafficked persons. There are many reasons that may prevent a person who has been trafficked from disclosing information or cause them to alter details about themselves, their situation, their intentions or their family. Victims with family members at potential risk: Individuals often have family members, especially children, who may have a major impact on their decision-making, including decisions about their own safety and well-being. Victims with an intimate or familial relationship with their trafficker: In some cases, victims may have a personal relationship with the trafficker. Women may currently have, or have had in the past, a romantic relationship with their abuser. Children may be exploited by a family member or someone they look up to as a parental figure. Victim-perpetrator: Victims may have moved up from being a victim of trafficking to being a recruiter or manager of other trafficked persons. Each of these situations can complicate the provision and acceptance of assistance. For the trafficked person, these circumstances may pose problems of dual loyalty, ongoing fear or intimidation and wavering intentions about the future. Health care providers may find that patients do not keep appointments and are not able to adhere to treatment, or that patients health care needs become intertwined with other support needs. Responses to human trafficking Responses to human trafficking usually focus on three broad areas known as the three Ps : Prevention, Protection and Prosecution. Prevention activities include awareness-raising and education to warn potential victims about trafficking, for example, and activities to prevent exploitation of migrant workers. Protection encompasses the support mechanisms and resources aimed at assisting victims and ensuring their safety. Prosecution actions are associated with law enforcement and aimed at identifying, arresting and criminally prosecuting perpetrators of trafficking. The following chapter describes some of the evidence around the health risks and consequences associated with human trafficking and discusses the implications for providing health care.
23 CHAP Chapter 2: The health consequences of human trafficking TER TWO
25 CARING FOR TRAFFICKED PERSONS: GUIDANCE FOR HEALTH PROVIDERS 15 Chapter 2: The health consequences of human trafficking Trafficked persons may have health problems that are minor or severe, but few individuals are unscathed. Many will experience injuries and illnesses that are severe, debilitating and often enduring. Abuse, deprivation and stress-filled or terrifying circumstances are all hallmarks of human trafficking. The Protocol to Prevent, Suppress, and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime establishes the basis of the assistance measures that should be provided for trafficked persons [Article 6 (3)]: Each State Party shall consider implementing measures to provide for the physical, psychological and social recovery of victims of trafficking in persons, including, in appropriate cases, in cooperation with nongovernmental organizations, other relevant organizations and other elements of civil society, and, in particular, the provision of: (a) appropriate housing; (b) counselling and information, in particular as regards their legal rights, in a language that the victims of trafficking in persons can understand; (c) medical, psychological and material assistance; and (d) employment, educational and training opportunities. 6 6 Protocol to Prevent, Suppress and Punish Trafficking in Persons, Especially Women and Children, Supplementing the United Nations Convention against Transnational Organized Crime, United Nations, New York, See